Williams-Evan-An-Introduction-to-Motivational

Report
Evan Williams, PharmD
Assistant Professor of Pharmacy Practice
Husson University School of Pharmacy

I have no financial disclosures
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Clinicians can only provide patients with
clinical knowledge and education
Patients make the ultimate decision to change
What can clinicians do to influence patient
change?
◦ Scare tactics
◦ Lecture and educate
◦ Motivate the patient to change
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

Describe Motivational Interviewing (MI) and
its components
Identify tools pharmacists and pharmacy
technicians can use to help implement
Motivational Interviewing in their practice
setting
Review literature that supports the
effectiveness of Motivational Interviewing
4

MI is a collaborative, person‐centered form of
guiding to elicit and strengthen motivation
for change. MI is a style of communication,
not a technique.
True or False?
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
OARS in MI stands for
A. Open Communication, Active
listening, Reasoning with the patient, and
Seeking change
B. Oral arguments, Active listening, Rolling
with Resistance, and Summaries
C. Open-Ended Questions, Affirmations,
Reflective Responses, and Summaries
D. Ongoing dialogue, Affirmations,
Resisting the Righting Reflex, and
Seeking change
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
Developing discrepancy involves:
A. The patient discovering how current behaviors
conflict with personal values or goals
B. Telling the patient the negative results of
current behaviors
C. Allowing the patient to choose between two
treatment options
D. None of the above
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Think of a “bad” habit you have tried to
change
◦
◦
◦
◦
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Dietary habits
Exercise habits
Workplace habits
Relationship habits
How long did it take to realize that this habit
had a negative impact on you or others?
◦ Months? Years?
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Were you successful? Did you relapse?
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“Motivational Interviewing (MI) is a
collaborative, person‐centered form of
guiding to elicit and strengthen
motivation for change.”
Defined by the identification, examination,
and resolution of ambivalence about
changing behavior
– Ambivalence: Feeling two ways about behavior
change
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Method of communication
◦ Not a technique
◦ Increases mutual understanding
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Collaborative
◦ Honors patient autonomy
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Strengthens a person’s own motivation for
and commitment to change
◦ Patient-centered
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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William R. Miller
◦ Motivational Interviewing with Problem Drinkers
 Behavioral Psychotherapy - 1983

Stephen Rollnick and William R. Miller
◦ 1991 article
◦ Outlines clinical procedures

Has been revised and applied to many
settings
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.
Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy. 1983, 11 (2); pp 147-172
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Key Elements of MI
◦ Collaboration
◦ Evocation
◦ Autonomy
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Principles of MI
◦
◦
◦
◦
Express Empathy
Support Self Efficacy
Develop Discrepancy
Roll with Resistance
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Collaboration
◦ Dismisses hierarchy
◦ Builds rapport
◦ Non-confrontational
◦ Focus is mutual understanding
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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RG is a 57 year old male with hypertension and
hyperlipidemia. On questioning it is revealed that
he smokes about 1 pack of cigarettes daily. You
would like him to quit smoking.
Which of the following shows the spirit of
collaboration consistent with MI?
◦ A. You need to stop smoking now.
◦ B. What reasons do you have to stop smoking?
◦ C. If you continue to smoke, you are increasing your risk
for having a heart attack or stroke.
◦ D. Let me help you to stop smoking.
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Evocation
◦ Patients discover their own motivation and skills for
change
◦ Draw out the patients own thoughts and ideas
◦ “..lasting change is more likely to occur when the
client discovers their own reasons and
determination to change”
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Pharmacist: “I’ve noticed you have been late
filling these medications the last 2 months.”
Patient: “Yeah, I’ve been having a hard time
keeping up with things as I am moving to a new
home across town in a few weeks. I know taking
my medications is important but I’ve been so
busy lately that I forget sometimes.”
Pharmacist: “It sounds like you would like to take
your medications but it has been a tough time
dealing with the move.”
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Autonomy
◦ Ultimately it is the patient’s decision to change
◦ Empowers the patient and gives them responsibility
◦ As clinicians, we can encourage patients to develop
their own “SMART” goals
 Specific, Measurable, Achievable, Relevant, Timely
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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DK is a 44 year old patient newly diagnosed with
diabetes. After discussion, it is revealed that he
eats desserts for relaxation. When asked how he
thinks this impacts his diabetes, he states he
does not know.
The response that best exemplifies autonomy
consistent with MI is:
◦ A. “May I tell you some information about how sweet
foods impact your blood sugars?”
◦ B. “Sugary dessert foods increase your blood sugar and
negatively impact your diabetes.”
◦ C. “Here is a pamphlet about how foods impact blood
sugar.”
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Express Empathy
◦ See the situation from the patient’s perspective
◦ Gain perspective on what the patient’s motivation
may be
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“It sounds like this has been tough for you”
“It seems like this situation has been difficult
for you to accept”
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Support Self Efficacy
◦ Focus on strengths and skills patient already has
◦ Highlight previous successes
◦ Patient needs to believe that change is possible
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Develop Discrepancy
◦ Patients identify their values and goals
◦ Patients evaluate their current behaviors
◦ Ambivalence is discovered when conflict between
values/goals and behaviors is identified
◦ Change is more likely when patients realize their
behaviors are in conflict with their self‐identified
values or accomplishment of goals
◦ “On the one side, you feel unhappy that you cannot
keep up with your grandkids because of your COPD,
but on the other hand, you feel that smoking is one
of the only ways you can relax.”
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Roll with Resistance
◦ Do not challenge resistant statements
 Confronting resistance promotes defensiveness and
diminishes the likelihood of a patient finding their own
reasons to change
◦ Use the resistance as an opportunity to further
explore the patient’s views
◦ Be aware of when a patient is becoming frustrated
 Closed body language
 Negative verbal responses
 Shortened verbal responses
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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BG is an overweight veteran recently discharged
from the Air Force. He has gained much of this
weight since his discharge 14 months ago. The
pharmacist suggested that BG enroll in clinic
sponsored program for weight loss. BG declines
enrollment. BG states that he is just not willing to
exercise for 30 minutes 5 days a week because
he is just too exhausted after work.
Which response best exemplifies the spirit of MI?
◦ A. If you don’t lose weight, you are putting yourself at
risk for other serious problems.
◦ B. Could you try to exercise just a few days a week?
◦ C. How much are you willing to exercise?
◦ D. Why don’t you want to be healthy?
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OARS
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◦
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Open-Ended Questions
Affirmations
Reflective Responses
Summaries
RULES of Motivational Interviewing
◦
◦
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Resist the righting reflex
Understand the patient’s motivation
Listen with empathy
Empower the patient
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Elicit better responses from patients
Make a conversation less one-sided
Are not answerable with a simple yes or no
Open-Ended Question Words Closed-Ended Question
Words
How?
Why?
Tell me more about...
When?
What kinds of…
Do you?
Have you?
Can you?
Will you?
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Statements that recognize a patient’s
strengths
Help support self efficacy
◦ Tries to help patient believe change is possible
despite past failures
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Restate how the
provider perceives
the patient
Allows for increased
clarity
Allows the listener to
affirm the patient’s
feelings
Patient feels
understood
Words the
patient uses
What the
patient meant
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
Words clinician
hears
What the
clinician thinks
the patient
meant
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Reflection that recaps visit and highlights
important areas
Can clarify ambivalence and discrepancies
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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“I know what is best”
◦ Removes autonomy from the patient by insinuating
the patient does not know what is best for
themselves
◦ Re-establishes hierarchy
◦ Can undermine the patient’s motivation for change
◦ Can create conflict
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Patient’s reason for change is more important
than the clinician’s
Explore importance of changing
◦ Ask for a scaled answer
◦ Why is it that number and not another?
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Use reflective responses
◦ Allows patient to tell you more
◦ Clarifies patient’s concerns
◦ Confirms mutual understanding
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Be aware of body language
◦ Eye Contact
◦ Nodding
◦ Posture
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Do not “understand”
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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Patients must believe change is possible
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Failures can be demoralizing
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Focus on previous successes
◦ Even small victories can be uplifting
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Encourage the patient
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Let the patient know that they are in control
of the change
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
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DARN-CAT
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Desire (I want to change)
Ability (I can change)
Reason (It is important to change)
Need (I need to change)
Commitment (I will make changes)
Activation (I’m ready and prepared to change)
Taking steps (I am doing specific things to change)
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20Approach%2
0V4%20012911.pdf
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Ask questions that will elicit answers that are
consistent with DARN-CAT
◦ Developing discrepancy
 Desire
 Reason
 Need
◦ Change ruler
 Ability
 Activation
◦ SMART Goal Setting
 Ability
 Activation
 Taking steps
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What went wrong?
What could the pharmacist have done
instead?
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What principles of MI were used by this
pharmacist?
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How well did the change ruler work?
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What else could the pharmacist have done?
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What went right?
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What examples of change talk did the patient
give?
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What could the pharmacist have done to
improve?
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Growing body of evidence
◦ 6 references 1980-1989
◦ 78 references 1990-1999
◦ 707 references 2000-2009
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Most studies show MI to be beneficial
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Most studies have limitations
◦ Publication bias?
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◦
◦
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Small sample size
Weak comparator groups
Various providers offering MI
Providers have differing levels of training in MI
Difficult to assess the manner in which MI is used
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
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Effectiveness of MI on changes in fitness,
blood lipids, and exercise adherence of police
officers: an outcome-based action study
N=109 officers
◦ 67 officers completed the program (13 women, 54 men)
◦ Previously completed a “high performance training seminar”
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10-week program
◦ Goal to improve fitness, nutrition, and lipids
◦ Weekly meetings with health coach
 MI included to help the officers identify and achieve goals
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10-week endpoints were compared to baseline
Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and
exercise adherence of police officers: an outcome-based action study. Journal of Correctional Healthcare.
45
Pre and Post intervention Measurements
Variable
Pre Test
Post Test
Difference
p-value
SBP
127
119
8 (6%)
<0.001
DBP
82
75
7 (9%)
<0.001
% Body Fat
24.8
21.5
3.3 (13%)
<0.001
Total Cholesterol
188
175
13 (7%)
<0.001
HDL
49.5
56.8
7.3 (15%)
<0.001
LDL
113
96
17 (15%)
<0.001
Triglycerides
138
123
15 (11%)
<0.001
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Significant improvements in physical
fitness, blood pressure, and lipids for those
who completed the 10-week course
◦ Baseline values already at BP/Lipid goals
 Unknown cardiovascular/diabetes risks
◦ Changes in lipids comparable to low dose statin
◦ Changes in BP comparable to addition low dose ACEi
• Average Adherence to fitness regimen:
• 80% for cardiovascular activity
• 75% for strength training
http://summaries.cochrane.org/CD003823/ace-inhibitors-for-the-treatment-of-high-blood-pressure
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Limitations
◦ large drop out rate (42%)
◦ Selection Bias
 Those who completed study were likely more
motivated and active prior to study
◦ Results likely only reflective of increased exercise
◦ Short follow-up
 Were benefits maintained
 Is MI beneficial for long term lifestyle changes?
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Pattern of results show MI is likely
◦ To confer at least a 10% advantage in success
rates versus weak comparators
◦ To be as good or better than established
treatments
◦ To take less time and resources

Best outcomes may be using MI pretreatment
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
49
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Effective regardless of gender or age
Training level does not significantly impact
effectiveness
◦ Versatile

In what areas is MI most effective?
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
50
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
51
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
52
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Brit
J General Practice. 2005 April, pp 305-312
53
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Limitations
• Interventions ranged from 10-120 min (60 min most
common)
• Variable follow up periods

Usefulness
• Provides evidence that MI can elicit significant change
• Overall about 75% of studies show there was an effect
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych 2009;65(11) 1232-45
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of controlled clinical
trials. Brit J General Practice. 2005 April, pp 305-312
54
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Online resources or live classes

Begin small
◦ Try only adding one component at a time
◦ Reflective responses are a great starting point

Keep working at it
◦ It may feel uncomfortable the first few times

Add components as you become more adept
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

MI is a useful technique to help people
change
It is useful in combination with other
techniques for eliciting change
MI should not replace your method of patient
interaction, but enhance it
56


Motivational interviewing is a collaborative,
person‐centered form of guiding to elicit and
strengthen motivation for change.
Key Elements
◦ Collaboration
◦ Evocation
◦ Autonomy
57

Principles
◦ Express Empathy
◦ Support Self Efficacy
◦ Develop Discrepancy
◦ Roll with Resistance
58

Strategies for implementation
◦ OARS
 Open-Ended Questions
 Affirmations
 Reflective Responses
 Summaries
◦ RULE




Resist the righting reflex
Understand the patient’s motivation
Listen with empathy
Empower the patient
59

MI is a collaborative, person‐centered form of
guiding to elicit and strengthen motivation
for change. MI is a style of communication,
not a technique.
True or False?
60

OARS in MI stands for
A. Open Communication, Active
listening, Reasoning with the patient, and
Seeking change
B. Oral arguments, Active listening, Rolling
with Resistance, and Summaries
C. Open-Ended Questions, Affirmations,
Reflective Responses, and Summaries
D. Ongoing dialogue, Affirmations,
Resisting the Righting Reflex, and
Seeking change
61

Developing discrepancy involves:
A. The patient discovering how current behaviors
conflict with personal values or goals
B. Telling the patient the negative results of
current behaviors
C. Allowing the patient to choose between two
treatment options
D. None of the above
62
63
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









Anshel MH, Kang M. Effectiveness of motivational interviewing on changes in fitness, blood lipids, and
exercise adherence of police officers: an outcome-based action study. Journal of Correctional
Healthcare. 2008 14:48
Brief Motivational Interviewing for Veterans. TMS. VALU system. www.tms.va.gov
Burke B, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta analysis of
controlled clinical trials. Journal of Consulting and Clinical Psychology 2003; 71, 843-861
Hettema J, Steele J, Miller W. Motivational Interviewing. Annual Review of Clinical Psychology 2005; 91111
http://www.motivationalinterview.org/Documents/1%20A%20MI%20Definition%20Principles%20&%20A
pproach%20V4%20012911.pdf
Lundahl B, Burke B. The effectiveness and applicability of motivational interviewing. J Clin Psych
2009;65(11) 1232-45
Lundahl B, Tollefson D, Kunz C et al. Meta analysis of motivational interviewing: twenty five years of
research. Research on Social Work Practice 2009
Miller WR. Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy 1983;
11(2),147-172
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York:
Guilford Press.
Rubak S, Sandboek a, Lauritzen C et al. The efficacy of motivational interviewing: A meta-analysis of
controlled clinical trials. Brit J General Practice 2005; April, 305-312
Vasilaki E, Hosier S, Cox W. The efficacy of motivational interviewing as a brief intervention for
excessive drinking: a meta analytic review. Alcohol and Alcoholism 2006; 41, 328-35
64

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